THE 1ST UDAYANA INTERNATIONAL NURSING CONFERENCE
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66.Formation Of Mental Health Alert Village (DSSJ) Using The Application Community Mental Health Nursing (CMHN) Overcoming Symptoms Of Recurrence In Patients With Mental Disorders In Puskesmas II East Denpasar
Ni Made Dian Sulistiowati, , Made Oka Ari K, KadekEka S, KomangMenik Sri K ... 79 67.Validation Of The Dutch Eating Behaviour Questionnaire For Children (DEBQ-C). A
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Kalimantan Barat
Sylvianingsih, IkaWidiAstuti, Indah Mei Rahajeng ... 81 69.Analysis Risk Factors For Diabetic Foot Ulcer In RSUP Sanglah Denpasar
Desak Made Widyanthari, Ni LuhPutu Eva Yanti ... 82 70.The Experience Of Sasak Teenage Mother In Childbirth
IkaWidiAstuti, BaiqFitria S, Suratiah ... 83 71.Relationship Workload Nurses With Completeness Nursing Documentation In Angsoka
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Ida Ayu Sri Utamawati,KomangAyuMustriwati, MenikKomang Sri ... 84 72.Pattern Servical Cancer Detection As Preventif Effort Of Woman Reproductif
Problems In Primary Center Care Of Surabaya
Ni Ketut Alit A, Esti Yunitasari, Mira Triharini, Tiyas Kusumaningrum, Retnayu
Pradanie ... 85 73.The Determinant Of The Implementation Of Nursing Ethical Principles
Ni Putu Emy Darma Yanti, Hanny Handiyani, dan Kuntarti ... 86 74.Occupational Health Study Of Woman Porters In Badung Market
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Yanti ... 87 75.Cader As A “Pilar” To Increase Family’s Ability To Manage The Health Of The
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THE 1ST UDAYANA INTERNATIONAL NURSING CONFERENCE
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ANALYSIS RISK FACTORS FOR DIABETIC FOOT ULCER IN RSUP SANGLAH DENPASAR
Desak Made Widyanthari1), Ni Luh Putu Eva Yanti2) 1
Nursing Study Program, Faculty of Medicine, Udayana University Denpasar 2
Nursing Study Program, Faculty of Medicine, Udayana University Denpasar Email: desakwidyanthari@yahoo.com
Abstract
Diabetes Mellitus (DM) can develop many various complications, both macrovascular and microvascular. Diabetic Foot Ulcer (DFU) is a common complication in diabetic patients. Injuries and other problems in the feet is a major cause of morbidity, disability and mortality. Nurse is responsible to identify the risk factors of DFU so that the incidence of DFU can be prevented. This study aimed to determine the most influence factors on DFU incidence in RSUP Sanglah Denpasar. This study design was a case control study with 80 samples i.e. 40 DM patients with ulcer and 40 patients with non-ulcer. Multivariate analysis using multiple regression logistic was employed. From the total nine variables being studied only the history of recurrent ulcer or amputation variable that is statistically proven to affect the DFU (OR = 8.5; 95% CI: 2.1 - 33.5). Meanwhile, other variables do not prove to be statistically affect the DFU (the sensory neuropathy, the motor neuropathy,autonomic neuropathy, sex, foot care , history of DM, age and blood glucose levels). 54% the incidence of DFU influenced by factors studied, while 46% is influenced by other factors. It is reccommended that for a nurse to provide health education foot care, particularly preventive measures in clients who have a history of previous ulcer.
Analysis of Risk Factors for Diabetic Foot Ulcer in RSUP Sanglah Denpasar
Desak Made Widyanthari1), Ni Luh Putu Eva Yanti2)
1Nursing Study Program, Faculty of Medicine, Udayana University Denpasar
Telp: 0361-222510
desakwidyanthari@yahoo.com 2
Nursing Study Program, Faculty of Medicine, Udayana University Denpasar
Abstract
Diabetes Mellitus (DM) can develop many various complications, both macrovascular and microvascular. Diabetic Foot Ulcer (DF U) is a common complication in diabetic patients. Injuries and other problems in the feet is a major cause of morbidity, disability and mortality. Nurse is responsible to identify the risk factors of DFU so that the incidence of DFU can be prevented. This study aimed to determine the most influence factors on DFU incidence in RSUP Sanglah Denpasar. This study design was a case control study with 80 samples i.e. 40 DM patients with ulcer and 40 patients with non-ulcer. Multivariate analysis using multiple regression logistic was employed. From the total nine variables being studied only the history of recurrent ulcer or amputation variable that is statistically proven to affect the DFU (OR = 8.5; 95% CI: 2.1 - 33.5). Meanwhile, other variables do not prove to be statistically affect the DFU (the sensory neuropathy, the motor neuropathy,autonomic neuropathy, sex, foot care , history of DM, age and blood glucose levels). 54% the incidence of DFU influenced by factors studied, while 46% is influenced by other factors. It is reccommended that for a nurse to provide health education foot care, particularly preventive measures in clients who have a history of previous ulcer.
Keywords: risk factors, diabetic foot ulcer
Introduction
Nowadays diabetes mellitus (DM) became one of the chronic diseases worldwide wich prevalence increasing every year. This condition can occur due to sedentary lifestyle. According the IDF atlas of 2013, the number of diabetic patients in the world has reached 382 million people, and its prevalence is expected to rise 55% to 592 million people by the year 2035. Indonesia ranks seventh after China, India, USA, Brazil, Russia and Mexico to 10 major countries of DM patients with age 20-79 years (IDF, 2013).
If DM is not well handled, it will lead to various complications, both macrovascular and microvascular. One complication in diabetic patients are diabetic foot ulcers. The injuries and other problems in the feet is a major cause of morbidity, disabilit, mortality and if not handled properly will caused an amputation.
The prevalence of foot ulcers vary in some populations. Neuropathy, deformity, high plantar foot pressure, poor glucose control, duration of diabetes and age men are more at risk for diabetic ulcers (Frykberg, 2002). Neuropathy will inhibit signal, stimulation or disruption of communication in the body that allows individuals are not aware of the dangers on foot. Diabetic foot neuropathy may experience sensory, motor and autonomic (Soegondo, Soewondo & Subekti, 2013). Muller et al (2002) also pointed out that 23% of patients with ulcers also had a history of ulcers or previous amputations.
occur in diabetic patients with ≥ 10 years of age due to uncontrolled glucose levels that
enable the emergence of microvascular and macrovascular complications (Hastuti, 2008). Another factor affecting the incidence of diabetic ulcers are maladaptive behavior that includes less obedient in doing injury prevention, testing and treatment feet (Lypsky et al, 2004). Foot care is one of the primary prevention efforts in the management of diabetic foot ulcers which aims to prevent injury. This foot care that includes; I check my feet, cut nails properly, check the proper footwear and memebersihkan even check the inside of shoes before use.
The nurse as health care team is responsible for being able to doing early detection the risk factors so the incidence of diabetic ulcers diabetic ulcers or amputations can be prevented.
Design
This research is case control design. The independent variable of this research consisted of several risk factors ; gender, age, duration of diagnosed diabetes, blood glucose control, previous ulcer history, sensory neuropathy, motor neuropathy, autonomic neuropathy and foot care. The dependent variable is the incidence of diabetic foot ulcers. These samples included 80, consisting of 40 control group and 40 groups of cases. In the case group, the inclusion criteria are DM patients who experience diabetic foot ulcers in the September-October 2015, willing to become respondents.. In control group the inclusion criteria are : DM patients who did not have diabetic foot ulcers in the September-October 2015 and willing to become respondents. The exclusion criteria for both case and control group are patients who experienced a below knee amputation and loss of consciousness
The study was conducted at the Outpatient Interna Diabetic Centre and Outpatient Clinic Surgery RSUP Sanglah Denpasar.
Result
1) Characteristic of respondent
The majority of respondents are male, aged <60 years, undiagnosed DM <10 years , had a mean blood glucose levels are not controlled, have a history of ulcers, have sensory, motor and autonomic neuropathy and has less practice of foot care. Based on the results of the bivariate chi square test the data found that there was a significant association between a history of ulcers, sensory neuropathy, autonomic neuropathy, neuropathy motorik with the incidence of diabetic foot ulcers.
Table.1. characteristic of respondents
4 Blood glucose levels
Fasting 70-130 mg/dl
Table.2. Multivariate analysis models
Characteristic OR 95%CI P value
Sex
Age
Diagnose of DM
History ulcer/amputation
Sensory neuropathy
Motoric neuropathy
Foot care
Autonom neuropathy
2,6
0,3
0,5
8,5
3,2
2,5
0,5
0,8
0,7-9,5
0,1-1,3
0,2-2,2
2,1-33,5
0,9-12,1
0,6-10,8
0,2-1,7
0,1-4,5
0,16
0,11
0,36
0,002
0,09
0,21
0,27
0,82
Discussion
Based on the results of the bivariate using chi square, it found that there was a significant association between a history of ulcers, sensory neuropathy, autonomic neuropathy, neuropathy motorikdan with the incidence of diabetic foot ulcers.
There is a significant relationship between autonomic neuropathy with diabetic ulcers. The presence of autonomic neuropathy resulting in blood flow is not smooth, especially the legs do not get the nutrients properly. According Frykberg (2006), anhidosis arise as a result of sensorimotor neuropathy associated with disorders of the sympathetic pathway postganglion sweat glands. Clinical manifestations that arise as a result of neuropathy, sensory, motor and autonomic are dry skin, chapped and the incidence of callus. Their skin is dry and cracked it can be easier for port d entry of bacteria and accelerate the onset of ulcers.
Based on the results of multivariate analysis, the only variable known history of ulcers or amputations that are statistically proven to significantly influence the factors affecting diabetic ulcers. A history of ulcers or previous amputations increases the risk of recurrent ulcers, infection and subsequent amputation (Wu, Driver, Wrobel & Armstrong, 2007). During one year traced ulcer healing process, 60% of patients with a history of ulcer will develop into ulcers came back because the condition of the skin in that area is still unstable to get pressure, making it easier for the next occurrence of ulcers. The majority of recurrent ulcer incidence occurs on the plantar foot and the tip of the thumb. Therefore, patients at risk of recurrent ulceration should conduct checks / inspections more detail in this area. Galea et al (2009) mentions that during the 12 months of the wound healing process is the most time at risk for recurrent ulcer occurrence, so that in this period the patient should be followed up to monitor the possibility of recurrent ulcer.
Conclusion
Of the nine variables studied, only a history of ulcer or amputation variable is statistically proven to affect the incidence of diabetic foot ulcers. While the other variables did not prove to be statistically affect the incidence of diabetic foot ulcers, namely: their sensory
neuropathy, their motor neuropathy, sex male, foot care irregular, undiagnosed DM ≥ 10 years of age ≥ 60 years, autonomic neuropathy and the average blood glucose levels. 54% ulcer incidence is affected by the factors studied, while 46% is influenced by other factors. It is advisable to conduct further research on the factors that influence the incidence of recurrent foot ulcers in diabetic patients.
Reference
Alex,R.,Ratnaraj,B.,Winston,B.,Devakiruba,N.S.,Samuel,C.,& et al. (2010). Risk factors for foot ulcers in patients with diabetes mellitus a short report from vellore south India.
Indian J Community Med.35(1):183-185
American Diabetes Association. (2014). Standards of medical care in diabetes 2014.
Diabetes Care. 37 (1): s14-s80.
Andreassen, C.S.,Jakobsen,J.& Andersen, H. (2006). Muscle weakness: a Progressive Late Complication in Diabetic Distal Symmetric Polyneuropathy. Diabetes. 55(3), 806-812.
Boulton,A.J.,Vinik,A.I.,Arezzo,J.C.,Bril,V.,Feldman,E.L.,& et al. (2005). Diabetic neuropathies. Diabetes Care.28(4): 956-962
Chesbro,S.,Asongwed,E.,Brown,J.,& John,E. (2011). Reliability of doppler and stethoscope methods of determining systolic blood pressure: consideration for calculating an ankle brachial index. J Natl Med Assoc.103;863-869
Clayton,W.,& Elasy,T.A.(2009). A review of the pathophysiology, classification and treatment of foot ulcers in diabetic patients. Clinical diebetes.27(2): 52-58
Dahlan, M.S. (2011). Statistik untuk kedokteran dan Kesehatan. Jakarta: Salemba Medika.
Diani,N. (2013). Pengetahuan dan praktik perawatan kaki pada klien diabetes melitus tipe 2 di Kalimantan Selatan. Depok: Fakultas Ilmu Keperawatan Program Magister Keperawatan Universitas Indonesia
Dros,J.,Wewerinke,A.,Bindels,.P.J.,& Van Weert,H.C.(2009). Accuracy of monofilament testing to diagnose peripheral neuropathy. A systematic review. Annals of Family Medicine, 7(6): 555-558
Frykberg,R.G.,Zgonis,T.,Armstrong.,D.G.,Driver,V.R.,Giurini,J.M.,Kravitz,S.R.,Landsman, A.S.,et al (2006). Diabetic Foot Disorders a clinical practice guidelines (2006 revisions).The journal of foot & ankle surgery, 45 (5).
Frykberg,R.G.(2002). Diabetic foot ulcers:pathogenesis and management. Am Fam Physician.66:1655-1662
Galea,AM.,Springett,K.,Bungay,H.,Clift,S.,Fava,S.,&Cachia,Mn.(2009). Incidence and location of diabetic foot ulcer recurrence.The Diabetic Foot Journal. 12(4):181-186
Hastono, S, P. (2007). Basic data analysis for health research training. FKM UI.
Hastuti,R.T. (2008). Faktor-faktor risiko ulkus diabetika pada penderita diabetes melitus. Semarang: Program studi magister epidemiologi program pascasarjana universitas Diponegoro Semarang
Hirsh, A.T.,Haskal, Z.J.,Hertzer, N.R.,& et al. (2006). ACC/AHA 2005 guidelines for the management of patients with peripheral arte-rial disease (lower extremity, renal, mesenteric, and abdominal aortic). Circulation,113; 463-654
IDF diabetes atlas 2013. June 10, 2014.
http://www.idf.org/sites/default/files/EN_6E_Atlas_Full_0.pdf
Lemaster,J.W.,Mueller,M.J.,Reiber,G.E et al.(2008). Effect of Weight Bearing activity on Foot Ulcer Insidence in People with Diabetic Peripheral Neuropathy. Journal of Physical Therapy, 88, 1385-1398
Nwarbudike,L.C & Tirgoviste,C.I.(2008). Risk factors and clinical characteristics for foot ulcers in patients with diabetes in bucharest romania. Proc Rom Acad.1-2:49-52
PERKENI. (2011). Konsensus pengelolaan dan pencegahan diabetes melitus tipe 2 di
Indonesia. April 06, 2013.
www.perkeni.org/download/Konsensus%20DM%202011.zip
Polit., & Beck. (2012). Nursing research generating and assessing evidence for nursing pratice. Philadelphia: Lippincott William & Wilkins.
Sastroasmoro,S., & Ismael, S. (2011). Dasar-dasar metodologi penelitian klinis
(4 th ed). Jakarta: Sagung Seto
Setacci, C., De Donato, G Setacci.,F.Chisci. (2010). Ischemic foot: Definition, Etiology and Angiosome Concept. Journal of Cardiovascular Surgery. 51,2, 223.
Soegondo,S., Soewondo,P., & Subekti, I. (2013). Penatalaksanaan diabetes melitus terpadu
(2 nd ed). Jakarta: Balai Penerbit FK UI
Sudoyo,W., Setiyohadi,B., Simadibrata,M., Alwi I., & Setiati,A. (2009).Buku Ajar Ilmu Penyakit Dalam.(5 th ed). Jakarta: Interna Publishing
Tarwoto. (2012). Keperawatan medikal bedah gangguan sistem endokrin. Jakarta: Trans Info Medikal
Van Schie,C.H.M.,Vermigli,C.,Carrington,A.L. & Boulton,A. (2004). Muscle weakness and foot deformities in diabetes relationship to neuropathy and foot ulceration in
caucasian diabetic men. Diabetes Care, 27:1668-1673
